Multispecialty system-based disease management programs have been implemented for several musculoskeletal diseases and in multiple healthcare environments in the U.S. and other countries.21,23,28-32 They have also been reported for other chronic diseases such as congestive heart failure, diabetes, and mental health problems, among others.22 Such management programs have out- performed traditional care and have generally utilized existing manpower and resources. These experiences suggest that such programs could be disseminated with modest new investments and with immediate impacts on costs and morbidity.12,13 This is where Kaiser Permanente, Geisinger, and other organizations that have already implemented a Medical Home program are heading. We think that this is for the right reasons. It is safe to assume that no increased number of providers and amount of other resources will improve anything if the delivery of care stays the same.
Accountable Care Organizations (ACOs) have been proposed recently for providing more effective healthcare and shifting how providers are paid from individually through fee-for-service to collectively for “episodes of care.”33,34 CMS is piloting the ACO concept for Medicare within currently integrated health systems, and approaches are being considered for encouraging traditional health systems to evolve into ACOs. The challenges inherent in achieving these changes are well recognized, as is the requirement for effective primary care within ACOs.35 System-based care management for chronic diseases is also required for the success of ACOs, and the Medical Home as currently defined is not sufficient for this task.
The requirements that we consider essential for developing system-based chronic disease programs are listed in Table 1 (p. 17) with informative references related to each. Discussing these requirements in detail is beyond the scope of this article, in which we are focused instead on the advantages of this approach compared with the current Medical Home proposals.
How Do You Stop a Train That Has Already Left the Station?
The Medical Home philosophy is a good one, because its goal is to improve the patient well-being and healthcare experience while simultaneously reducing cost. The Medical Home proposes to do so by taking a holistic approach to the patient, and integrating community resources with medical resources to provide for the total needs of the patient. The problem lies in the management of chronic diseases, where most of the cost and care is done on the specialty side. By not defining the role of the specialist, the Medical Home model in its current design will likely result in restricted or haphazard specialty involvement, and will do nothing in the long term for the cost of care.